Social Worker

Mount Sinai Medical Center•Hialeah, FL

12d

About The Position

The Social Worker conducts psychosocial assessments and reassessments for Eldercare participants, collaborates with the interdisciplinary team to develop and coordinate care plans, and supports participants and families through counseling, education, advocacy, referrals, and care transitions. The role includes helping participants access housing, community resources, benefits, and advance-care planning, as well as providing end-of-life support when appropriate. The Social Worker also participates in quality improvement initiatives and works within the scope of their professional authority while adhering to Eldercare’s philosophy and goals.

Requirements

Master of Social Work degree from a school accredited by the Council on Social Work Education.
BLS or CPR certification is required.

Nice To Haves

Two years of social work experience on an interdisciplinary team in a hospital, nursing home, or community-based setting is desired.
One year of experience working with a frail and elderly population.

Responsibilities

Perform in-person initial enrollment assessments and obtain a complete psychosocial history, including cognitive status, social supports, family dynamics, mental health, substance dependency, and current issues and needs.
Collaborate with the interdisciplinary team to develop a comprehensive care plan for each participant.
Conduct in-person reassessments every six months and as needed when participants’ conditions change.
Attend daily interdisciplinary team meetings, communicate participant changes, and collaborate on care planning and coordination for 24-hour care delivery.
Act as a liaison among participants, caregivers, community agencies, the interdisciplinary team, the day center, and other Eldercare staff.
Provide ongoing support, counseling, and education to participants and families on aging, dementia, grief and loss, end of life, disease processes, family dynamics, changing roles, and Eldercare services.
Present requests to the interdisciplinary team and coordinate participant admission to or discharge from contracted facilities for respite or permanent placement.
Facilitate and mediate meetings with participants, families, caregivers, and community agencies to clarify or resolve issues, including care plans.
Refer participants to subsidized housing and assisted living residences; assist with applications, medical records, interviews, and tours when needed.
Refer participants to community resources such as Adult Protective Services, Housing Authority, and utility companies, and advocate to help maintain community stability.
Assist participants and caregivers with advance directives, Medical Durable Power of Attorney, proxy, and Do Not Resuscitate directives.
Assist participants with Social Security Income and Social Security Disability Insurance applications.
Help participants disenrolling from Eldercare coordinate insurance and referrals for other community- or facility-based services.
Provide emotional support, grief counseling, education, and funeral or financial planning referrals when end-of-life care is appropriate; facilitate end-of-life or nursing home placement as needed.
Participate in and support quality improvement initiatives.
Practice only within the scope of professional authority and adhere to Eldercare’s philosophy and goals.